World Society for Pediatric Infectious Diseases calls for action to ensure fair prices for vaccines
Authors: Fiona M Russell, Asha Bowen, Mark Cotton, Abiel Mascareñas, Miguel O'Ryan
Journal: The Lancet Global Health (2023)

The eradication of smallpox is considered one of the greatest achievements of humankind, thanks to vaccination. The widespread availability of childhood vaccines has substantially reduced childhood morbidity and mortality.1Li X Mukandavire C Cucunubá ZM et al.Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: a modelling study.Lancet. 2021; 397: 398-408Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar Devastating infections, such as polio, have almost disappeared due to vaccination. In 2021, it was estimated that vaccination against ten selected pathogens will have averted 69 million (95% credible interval 52–88 million) deaths between 2000 and 2030. Increases in vaccine coverage and introduction of additional vaccines should reduce lifetime mortality by 72% (59–81 million) in the 2019 birth cohort.1Li X Mukandavire C Cucunubá ZM et al.Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: a modelling study.Lancet. 2021; 397: 398-408Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar However, access to vaccines that prevent life-threatening and disabling infectious diseases remains unequal.2Rodrigues CMC Plotkin SA impact of vaccines; health, economic and social perspectives.Front Microbiol. 2020; 111526 Crossref Scopus (209) Google Scholar Much has been learned during the COVID-19 pandemic in terms of developing vaccines efficiently, but as more infectious diseases become vaccine-preventable, these expected public health gains will only further improve if coupled with equitable access to vaccines. Gavi, the Vaccine Alliance, plays a critical role in making vaccines accessible for low-income and lower middle-income countries. However, the introduction of new vaccines is slow, especially in low-income and middle-income countries (LMICs) that are not Gavi-eligible.3GaviGavi's approach to engaging with middle-income countries.https://www.gavi.org/types-support/sustainability/gavi-mics-approach#:~:text=In%20this%20context%2C%20the%20MICs,select%20never%2DGavi%20eligible%20countriesDate: March 13, 2023Date accessed: September 8, 2023Google Scholar Despite pneumococcal conjugate vaccine (PCV) being available for over 20 years, and pneumococcal pneumonia causing approximately 300 000 deaths in children each year, 28 countries (mostly middle-income) are yet to introduce this vaccine into their national programmes.4International Vaccine Access CenterJohn Hopkins Bloomberg School of Public HealthVIEW-hub.www.view-hub.org/vaccineDate accessed: September 5, 2023Google Scholar 71 countries have not yet introduced rotavirus vaccine, and 63 countries have not introduced human papillomavirus (HPV) vaccine, despite it having been available for 17 years.4International Vaccine Access CenterJohn Hopkins Bloomberg School of Public HealthVIEW-hub.www.view-hub.org/vaccineDate accessed: September 5, 2023Google Scholar Profoundly inequitable access to COVID-19 vaccines has been widely reported.5Wouters OJ Shadlen KC Salcher-Konrad M et al.Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment.Lancet. 2021; 397: 1023-1034Summary Full Text Full Text PDF PubMed Scopus (703) Google Scholar In contrast, there is very little attention paid to the long-standing inequitable access to childhood vaccines, especially in middle-income countries. Vaccine price is a major barrier to national introduction6Guillaume D Meyer D Waheed DEN et al.Factors influencing the prioritisation of vaccines by policymakers in low- and middle-income countries: a scoping review.Health Policy Plan. 2023; 38: 363-376Crossref PubMed Scopus (1) Google Scholar and a major driver of cost-effectiveness. As countries transition from Gavi support to self-financing, budget constraints due to competing priorities made worse by the COVID-19 pandemic often lead to difficulties in sustaining procurement and coverage. These budget constraints lead to further inequity for hard-to-reach populations, and is a barrier to introducing new vaccines.7Immunization Agenda 2030Middle-income countries immunization agenda.https://www.immunizationagenda2030.org/images/documents/IA2030_MIC_Annex_draft_FINAL.pdfDate: 2023Date accessed: September 8, 2023Google Scholar The persistent gap in vaccine access between high-income and lower-income countries remains a major challenge and jeopardises the Sustainable Development Goal (target 3.2) for child survival. Countries without financial support from Gavi also face procurement challenges, especially for new vaccines. Gavi's price negotiations, large purchasing power, and procurement mechanisms are essential for ensuring affordable vaccines. Countries transitioning from Gavi to self-financing or self-procuring need to establish alternative strategies for vaccine procurement and negotiate favourable terms independently with suppliers. For example, the affordable price negotiated by Gavi for the quadrivalent HPV vaccine is expected to expire by the end of 2025 for transitioned countries. Moreover, countries that were never Gavi-eligible but classified as middle-income—including small island developing states—face even more challenges, which have delayed their introduction of PCV, rotavirus, and HPV vaccines by up to 20 years. PCV, rotavirus, and HPV vaccines have few manufacturers, and some middle-income countries pay more per dose than high-income countries.8WHOGlobal vaccine market report 2022: a shared understanding for equitable access to vaccines. World Health Organization, Geneva2023Google Scholar The WHO Market Report found that the average PCV and HPV vaccine prices differed by approximately 18 times between the highest and lowest price. For countries that self-procure vaccines, the average prices of PCV, rotavirus, and HPV vaccines increased between 2019 and 2021 by 43%, 55%, and 63%, respectively.8WHOGlobal vaccine market report 2022: a shared understanding for equitable access to vaccines. World Health Organization, Geneva2023Google Scholar Additionally, the lack of transparency and competition in the vaccine market further limit options for affordable alternatives. Moreover, health-system challenges, including weak infrastructure, insufficient funding, logistical barriers, and lack of purchasing power, compound the problem and restrict the ability to negotiate affordable vaccine prices. Since 1979, the Pan American Health Organization (PAHO) has facilitated pooled procurement of vaccines for countries in the Americas, most of which are middle-income self-financing countries. By leveraging the collective purchasing power of member states, the PAHO Revolving Fund negotiates favourable vaccine prices, ensuring cost savings and equitable access. However, challenges with vaccine prices persist, especially as suppliers are pushing for tiered pricing strategies to gain further profits. Such market dynamics, and global supply negotiations without the inclusion of PAHO (ie, by Gavi and UNICEF), can potentially jeopardise PAHO's affordable procurement for countries in the Americas that have economic statuses similar to Gavi-transitioned countries. Overcoming these challenges requires procurement strategies that benefit all LMICs and the promotion and protection of regional cooperation to achieve affordable and sustainable vaccine access. PAHO will be an important role model of pooled procurement for Africa and other regions. The COVID-19 pandemic has further highlighted the urgent need for middle-income countries to develop and manufacture their own vaccines. A study estimating the societal and economic benefits at the country level and regional level of investing in regional hubs for vaccine development found that the benefits far outweighed the investment.9Schäferhoff M Zimmerman A Diab MM et al.Investing in late-stage clinical trials and manufacturing of product candidates for five major infectious diseases: a modelling study of the benefits and costs of investment in three middle-income countries.Lancet Glob Health. 2022; 10: e1045-e1052Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Successful examples include the partnership with the Serum Institute of India for the meningococcal A conjugate vaccine in Africa,10Bishai DM Champion C Steele ME Thompson L Product development partnerships hit their stride: lessons from developing a meningitis vaccine for Africa.Health Aff (Millwood). 2011; 30: 1058-1064Crossref PubMed Scopus (41) Google Scholar and now PCV globally. Currently, less than 1% of vaccines in Africa are locally manufactured. The African Union aims to procure 60% of Africa's vaccines from local manufacturers by 2040.11Africa Centres for Disease Control and PreventionAfrica calls for new public health order.https://africacdc.org/news-item/africa-calls-for-new-public-health-order/Date: Sep 29, 2022Date accessed: October 16, 2023Google Scholar The COVID-19 pandemic has imposed tremendous economic and social challenges worldwide, and concerns over vaccine access and affordability are rising. The scientific community has learned much on vaccine development during the pandemic, but there remain profound and widening gaps for equitable vaccine access. Despite the lifesaving potential of the new respiratory syncytial virus vaccine for infants or through maternal vaccination in low-income countries, it is unlikely that these children will be protected for many years. Vaccine price should not be a barrier to the introduction or sustainability of immunisation programmes. Therefore, the World Society for Pediatric Infectious Diseases calls for fair pricing for all vaccines to ensure that they are global public goods. We ask governments and international organisations to act urgently to protect the lives of present and future generations via global, equitable access to affordable vaccines through a comprehensive approach (panel).PanelRecommended actions by stakeholders for achieving fair vaccine prices for low-income and middle-income countries (LMICs)Pharmaceutical companies •Commit to fair, equitable pricing strategies for vaccines, considering the socioeconomic context of all LMICs, and publish pricing by income status of countries•Facilitate technology transfer and knowledge sharing to enable local production, local fill and finish technology, and reduce dependence on importsGovernments and international organisations •Negotiate affordable pricing structures en bloc with regional states and pharmaceutical companies, promoting transparency and fair competition, and commit to publishing pricing by income status•Explore alternative procurement strategies and promote regional cooperation and support efforts, such as the Pan American Health Organization's Revolving Fund to Access Vaccines and UNICEF's Pacific Vaccine Independence Initiative•Support technology transfer and capacity-building initiatives to enhance local vaccine production, such as the WHO-supported mRNA technology hub in South AfricaResearch and development funders •Increase investments in research and development of vaccines, specifically targeting diseases prevalent in LMICs•Encourage partnerships between academic institutions, pharmaceutical companies, and international organisations to foster vaccine research and innovation, and improve affordabilityGlobal health initiatives •Strengthen international collaborations to address vaccine inequity, and include all countries with low availability of public health funds irrespective of World Bank income classifications•Advocate for policies and mechanisms that promote equitable vaccine access, including flexibilities Pharmaceutical companies •Commit to fair, equitable pricing strategies for vaccines, considering the socioeconomic context of all LMICs, and publish pricing by income status of countries•Facilitate technology transfer and knowledge sharing to enable local production, local fill and finish technology, and reduce dependence on imports Governments and international organisations •Negotiate affordable pricing structures en bloc with regional states and pharmaceutical companies, promoting transparency and fair competition, and commit to publishing pricing by income status•Explore alternative procurement strategies and promote regional cooperation and support efforts, such as the Pan American Health Organization's Revolving Fund to Access Vaccines and UNICEF's Pacific Vaccine Independence Initiative•Support technology transfer and capacity-building initiatives to enhance local vaccine production, such as the WHO-supported mRNA technology hub in South Africa Research and development funders •Increase investments in research and development of vaccines, specifically targeting diseases prevalent in LMICs•Encourage partnerships between academic institutions, pharmaceutical companies, and international organisations to foster vaccine research and innovation, and improve affordability Global health initiatives •Strengthen international collaborations to address vaccine inequity, and include all countries with low availability of public health funds irrespective of World Bank income classifications•Advocate for policies and mechanisms that promote equitable vaccine access, including flexibilities MC has previously received a grant from the Serum Institute of India, unrelated to this article. MO'R has previously received grants from Pfizer and Jannsen, unrelated to this article. All other authors declare no competing interests.